USVH Disease of the Week #3: Dementia in Older Adults and Veterans“Managing Common Behavioral Problems in Dementia: How to Improve Quality of Life forPatients and Families”James R. Burke, MD, PhD; Joel C. Morgenlander, MDVOL 106 / NO 5 / OCTOBER 15, 1999 / POSTGRADUATE MEDICINEAlthough memory loss is an early and prominent finding in most patients with dementia, thechief factor leading to
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CABBIT WAKES UP around 2:00 in the afternoon. She walks out of her
room wearing only a thong and an outgrown shirt. Her hair is a wild corona.
Wearing glasses but not makeup, she looks much younger than her 20 years. She
pads over the stained carpet of her apartment to the cold linoleum of the kitchen
and sets to work. Opening the dishwasher, she rearranges its contents and makes
sure fork prongs, knife-edges and the smooth inlays of spoons are turned up in
the same direction. Cups, plates and pans are more efficiently packed in: mug
handles must all curve in the same direction; matching plate sets are grouped
together. Her mother never uses incomplete diningware sets. Cabbit often recites
this fact like it is a parable; the point being that domestic compulsiveness is
passed down genetically. Also passed down genetically are Cabbit’s wide blue
eyes and petite frame. These attributes will probably always make Cabbit look
much younger than her years.
This morning’s wake-up procedural is a small way for Cabbit to normalize the previous night’s events. A makeshift system for making amends, she can build the day upon its order. The ritual is disrupted this afternoon by her ex-boyfriend Mark who walks out of her room fully dressed. There is a cordial goodbye scene: Have a good day! A quick wave; Mark leaves. (The previous morning involved a scene much like this one but with a different boy who sang loudly in her shower and played piano for a living.) Cabbit throws away an empty wine bottle from the night before and sanitizes a countertop. She switches on the coffeepot then sits down at the glass-topped dining room table wedged between the kitchen and pantry/storage closet. She draws her bare legs up so the bend of her knees is level with her chin and does not say a word. Cabbit has the Imperial March as her ring tone; her screensaver is programmed to mimic the falling, fluorescent green numbers from the Matrix movies. She owns a medieval wench costume she wears annually to the Renaissance Faire. “You’re really cute,” she is often told. “I’m really just a fat Goth trapped in a cute girl’s body” Cabbit likes to respond. She reads manga and loves anime porn. Last year, for Halloween, she dressed as a murderous Alice in Wonderland wearing platform shoes and a blood-spattered apron. She is studying abnormal psychology at Irvine Valley College; she has memorized the biographies of infamous madmen like Albert Fish and Jeffrey Dahmer. Cabbit traces her interest in dark material to her childhood: “ When I was growing up people would describe me as being intelligent for my age and mature. But I was the one in class always getting picked on. I was the scapegoat in the group. If things went wrong it was my fault.” Her mother yelled at her so often that Cabbit remembers her as always having a raspy voice. “Later my mom and dad went to a class called Growing Kids God’s Way at Pacific Hills Christian Church, and she stopped yelling as much. She told us that God was making her voice raspy to get her to stop yelling.” Cabbit remembers her teenage years as being full of conspirators; her description of high school politics implies the bloody coups of Latin America don’t just happen in Latin America. Cabbit’s involvement in extracurricular activities reads like a list of deposals. She was ousted as President of Anime club by her own members because they believed she was less dedicated to the well-being of the club than to her dictatorship of it. She was stripped of the Editor-In-Chief title by her journalism teacher. Cabbit believes a young rival was whispering into the teacher’s ear. She recalls the advisor of her high school’s stand-up comedy troupe Comedy Sportz as a “total bitch” who also “had it out” for her. The boys on the team may have always been rude to Cabbit but the advisor was the one who kept her from going on to the video production team Diablo Heat. “She must have badmouthed me to the judges,” says Cabbit. Her image of herself as a scapegoat stayed after childhood left. And, in this regard, Cabbit’s perception of herself is not far off. It has something to do with her habit of divulging intimate secrets to strangers and, occasionally, misapplying her social confidence. It makes her an easy target. Toward evening on the same day, Cabbit’s cell phone rings. She looks at the caller ID and smiles. It is the boy who sings in her shower. Her hello is flirty and eager. He wants to know why Cabbit petitioned his girlfriend for a threesome last night at the bar. “I was talking to her, and I just got this vibe that she was into it,” Cabbit enunciates carefully. “So I floated it out there- I just said if you’re into this and if you are it is totally cool and if you’re not do not even worry about it but what do you feel about threesomes?” The disconnected voice at the other end sounds insistent and angry. Cabbit’s eyes lose some of their shine. Continuing to speak coyly, Cabbit responds: “Well, Allison is a sexy girl and I have to admit, the fact that she was wearing panties at the bar last night really turned me on.” She listens some more. Her face stiffens. “The threesome proposition was innocent. It was supposed to be fun!” The water in Cabbit’s fish tank has not been cleaned in weeks. Green shadows emanate from murky depths and sidle across the opposite living room wall. The goldfish inside-- Ingeborg, Hirohito, Matisse 2 and Minnow 3--swim nervously around the squat Buddha-head tank accessory bought on a whim, as were the fish and tank. “No home is complete without a pet,” Cabbit said at the time. She spent over $100 on the artificial light, water filter, blue pebbles and tank-cleaning snails. The goldfish were free. Five have already died. That Cabbit chose to buy such an expensive ecosystem for a type of fish won at county fairs and brought home in Ziploc baggies at first seems like an example of inverse logic. But it isn’t actually. The goldfish are representational; Cabbit does not so much deem their lives worthy as much as the idea behind keeping them alive: responsibility, possible growth, the eventual attainment of adulthood. Cabbit is constantly working toward an ever-shifting set of goals, but the volatility of these future plans never seems to matter to her. The point is not to close the gap between the distant shimmer and the workable present; no, the point is the distant shimmer and the joy is the dreaming and the planning and talking. There are moments when she is driving and has a seizure of happiness. Her hope outstrips wherever she is going and she has a vision of future bliss. Down that road, every light turns tantalizingly green: Medical School in Antigua, getting engaged to Mark, a job she can wear “actual work clothes” to (she currently works as a waitress). Cabbit’s most persistent dream though is to live in a bigger, better apartment. Brochures for St. Moritz Condominiums and The Apartments at City Lights litter her living-room table. She compares and contrasts floor plans and asks every tour guide if their residences have a washer and dryer on the inside. She often retells the story of bickering with Mark over whether their future condo should have a bathroom outside or inside their master bedroom; he opted for the latter: “Mark never thinks about having guests over,” she says. But Cabbit, nestled into the sofa diagonally across the room from the fish tank, cannot afford a larger apartment. Things add up (rent, car payments and insurance and gas, several unpaid speeding tickets, sudden impulse shopping), and credit cards have limits. She has her pajamas on and contact lenses out because she has been feeling sick most of the day. Earlier, she went to the gynecologist to get her last dose of the HPV vaccine. Even though the shot always makes her feel like crap, she still enjoys proselytizing about its health benefits. Most of her friends have been subjected to a rehearsed litany of Gardasil pros. Though sometimes uncomfortable, Cabbit’s concern for the sexual health of her female friends (or passing acquaintances) is her way of showing affection. Sex figures prominently in all of her ways of showing affection. She is quick to point it out that this may be a product of her “addictive-impulsive personality.” Or she could just like sex. When Cabbit was 15, she rigged up an elaborate escape system in order to sneak out the window of her second-story room. Every Sunday for an entire summer she met a 24- year-old man at a neighborhood gym. He respected Cabbit’s high maturity level; she always hated being thought of as a kid. They would rendezvous at the back of the gym, in the dark and airless confines. Cabbit fell in love with him and her newfound sexuality on the gym’s smooth, grooved mats. Summer was over and the Santa Anas were beginning to make noses bleed when this childhood affair ended badly on those same mats. She was not quite mature enough to have sex with him. She panicked. He was not in love with her, in turns out. Cabbit remembers climbing back through her window that night and sobbing until she was exhausted. When she woke up in the morning, the world was on fire. The Santa Anas had fueled a wildfire that set ablaze hills near Cabbit’s house. “These weird black and yellow clouds blotted out the sky and ash was everywhere,” Cabbit remembers. “I knew life was never going to be the same.” Still curled into the sofa, Cabbit’s attention is drawn from the television when Amanda, her oldest friend, walks through the front door. “Oh my God! I friggin’ hate the sound of that fish tank,” she yells first thing. “I couldn’t fall asleep out here the other night because it sounded like a racehorse pissing.” . “Are you ready to go?” asks Cabbit. Cabbit, still in her pajamas, is accompanying Amanda to CVS pharmacy. Amanda did not want to buy the morning-after pill by herself. Too embarrassing. A few nights ago she broke up with her boyfriend because she suspected him of being addicted to online gambling. Amanda’s mother is a recovering alcoholic; she knows the signs. She went out with some friends to forget about him. Purposefully drank too much. Now this “morning-after” issue. “You know someone is truly addicted when the unhealthy relationship they have with something is put in front of the relationships they have with the people they love,” Cabbit says, with all the seriousness of someone who has taken several credits of junior college psychology. Cabbit likes to think of herself as someone who knows something about addiction. She suffered from migraines in high school and was prescribed so many heavy-duty painkillers that, according to her, she was zombied-out most of her Sophomore year. “I was addicted to those painkillers. They numbed everything for me. Nobody knew, but I had a pretty bad withdrawal when I got off them.” Cabbit’s salvation during this period was a poem she discovered in a high school textbook: All day the darkness and the cold/ upon my heart have lain; / like shadows on the winter sky, /like frost upon the pane… That was exactly how she felt at the time. Just totally depressed. Cabbit’s sense of the significant is somewhat jumbled--a faulty transmission of ideas from bad television or misunderstood reading. This sense is currently directing her to tattoo this line of poetry alongside an image of Ganesh on the left side of her ribcage. “So that I’ll never forget the hard times,” she says. Ganesh is an Indian god. He is, according to Cabbit, the remover of obstacles and bestower of prosperity. He also has the head of an elephant. Indian restaurants often portray him sitting on a throne in red or gold saris holding aloft a lotus flower. The line of poetry comes from “On Receiving an Eagle’s Quill from Lake Superior.” It was written in the nineteenth century by the American poet John Greenleaf Whittier, a well-known Quaker and Abolitionist. The poem seems to be about the joy of westward expansion; Cabbit does not seem to be aware of this. “Alright, let’s go,” says Cabbit. Mark is coming over soon to read to Cabbit in bed because she is sick. He is bringing The Lorax, her favorite Dr. Seuss book. Sitting behind the wheel of her black Toyota with the vanity license plate, Cabbit is getting very uncomfortable. She is wearing a puffy peasant chemise with a laced-up corduroy bodice over it. Breathing is difficult; movement is restricted; her chest swells voluptuously. A leather belt with a Celtic-knot design keeps two full-length purple and gold skirts in place. She has the skirts pulled up past her knees--exposing sensible brown loafers bought for an office job she kept only two weeks--so that the fabric does not get caught between her foot and the pedal of the car. This is Cabbit’s sixth year driving to the Renaissance Faire, and she is half an hour late to meet her friend Jessie. Late and lost. She accidentally got off the 57 East, exited somewhere in Chino Hills. Brown slopes and cracked roof shingles roll in every direction. She needs to concentrate so she turns down the volume on her Celtic Instrumental CD in the middle of “Scotland the Brave” and grips the steering wheel with both hands. It was Jessie who first introduced Cabbit to the Renaissance Pleasure Faire. Valentine’s Day, 10th grade, and Cabbit was sitting alone by the school vending machines filling out cards. She was wearing her favorite Hot Topic shirt, “Protected By Vampires” in bold letters across the front. Jessie walked by and noticed Cabbit’s awesome shirt. She kept walking past trying to get Cabbit’s attention, but Cabbit was absorbed with her cards. Jessie finally decided she needed a different approach and yelled out, Anne Rice was the greatest author of all time. An instant Goth-Erotica connection was made. The random meeting eventually led to a friendship and an invitation to “RennFaire.” The first time Cabbit attended she remembers being worried that her thrown-together costume, one part leather bondage and two parts Japanese schoolgirl, was going to be stared at. She would learn, however, that RennFaire’s appeal lies in its casual acceptance of freakdom. RennFaire itself is a strange amalgamation of fantasy. It is possible to see Harry Potter, a half-naked fairy princess and an aging, half-baked hippie all cheering on the knights at a joust. Rotted telephone poles lean in unison down the Chino street; there is an empty golf course and dusty palms. Haze settles over the distant San Gabriels. Cabbit drives past a faded sign: “EXTREME BRUSH FIRE HAZARD! DANGER! NO SMOKING!” Then another: “DeVry University/Phoenix University 2 Miles.” “This is the type of place you end up when you’ve done something wrong with your life,” Cabbit says, accelerating past a neon orange advertisement for Club Spice (Call for the VIP List!). Idling at a stoplight, she notices the name of a stucco-box storefront, “Prenatal Peek.” “Getting pregnant doesn’t scare me,” she says. “I know Mark would be a great father. I mean, I don’t want it to happen till we’re married. But, you know, if it did.” If it did, this may or may not be the type of place Cabbit would end up: Miles from the coast, miles of apartments for lease and plenty of affordable mini-storage. The thought settles quietly until, with an excited clap, Cabbit dispels it, “I see an entrance ramp!” For the last two years, the Renaissance Faire has been held at the Santa Fe Dam in Irwindale, California. It is a place far outside the Los Angeles of California Dreamin’ idylls. Right off the Irwindale exit there is modest billboard planted in the chaparral: an Amtrak caboose roars past an oceanic sunset, “Escape” spelled in caps. Part of the San Gabriel River Watershed Management Plan, the Santa Fe Dam controls the mud and runoff from the swollen San Gabriel, keeping it from flooding residential neighborhoods. Instead, every spring, a torrent of persons wearing starched collars and buckled shoes, speaking the Queen’s English and smelling of cannabis, floods through the gates in the opposite direction. Cabbit parks in the lot nicknamed “The Dustbowl.” She adjusts her bodice and hides her Claritin (“I’m allergic to everything out here”) underneath the rabbit fur that lines her Renaissance basket. At the gate, she gets her hand stamped in red with the word “NOBLE.” Only FOF (Friends of Faire) members receive this stamp and Cabbit has worked the Faire enough to become one of its “Friends”--a rather small circle of people, many of whom work for Disney. Inside the gates, two Faire workers dressed as Puritans stroll past in black robes and bonnets. “Fancy a tumble in the hay, Puritan?” Cabbit yells to them. “That was my twin sister last night! The devil had possessed her!” answers the Puritan. Cabbit smiles, “That’s what they all say!”
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